Penetrating trauma of the neck

Penetrating neck trauma and the need for surgical exploration: six-year experience within a regional trauma centre

BACKGROUND

There has been a shift towards conservative management of penetrating neck trauma in selected patients.

METHODS

A retrospective case note review of the management of penetrating neck trauma (2007-2013) was undertaken at our large teaching hospital and compared against best-evidenced practice.

RESULTS

Sixty-three patients were admitted over six years. The incidence of penetrating neck trauma is reducing, contrary to our belief. Most cases were knife inflicted (33 out of 63), and of these most were attempted suicide. There was a high rate of negative findings for neck explorations under general anaesthesia (18 out of 22). Only nine cases had justification for general anaesthesia exploration according to best practice.

CONCLUSION

The rate of neck explorations under general anaesthesia has dramatically fallen, in line with best practice. The need for operative intervention in patients with penetration of the aerodigestive tract or a major vascular injury should be based on clinical features, and these have been shown to be reliable indicators prior to open exploration.

Selective management of penetrating neck injuries using "no zone" approach

INTRODUCTION

Selective management has been the standard management protocol in penetrating neck injuries (PNIs) since this approach has significantly reduced unnecessary neck exploration. The purpose of this study is to evaluate outcomes of selective management in PNIs using the "no zone" approach, in which the management is guided mainly by clinical signs and symptoms, not the location of the neck wounds.

MATERIALS AND METHODS

A retrospective study was performed in patients treated for PNIs at King Chulalongkorn Memorial Hospital (KCMH) from January 2003 to December 2013. The patients with hard signs of neck injury (i.e., active bleeding, significant haematoma, massive subcutaneous emphysema, and air bubbling through the neck wound) underwent emergency neck exploration. The asymptomatic patients and the patients with soft signs (other symptoms) were considered to be candidates for selective management. Data collection included demographic data, emergency department parameters, details of neck injury, and outcomes in terms of mortality, negative exploration rate, and missed injury rate.

RESULTS

Eighty-six PNI patients were treated at KCMH from 2003 to 2013, 64 of which sustained stab wounds, 12 gunshot wounds, 4 shotgun wounds, and 6 other causes. Thirty-six patients presenting with hard signs underwent immediate neck exploration and there were 2 negative explorations. Twenty-six patients with soft signs underwent selective investigations (including computed tomographic angiography in 21 patients), 5 patients required neck explorations due to positive results of the investigations with one negative exploration. All of the twenty-four asymptomatic patients were managed with close observation, none required subsequent neck exploration. There was no missed injury found in the present study. Successful non-operative management was carried out in 45 patients (52%). The overall negative exploration rate was 7% (3 in 41 patients undergoing neck exploration). Two patients with hard signs died from associated chest injuries (mortality rate 2%).

CONCLUSION

Selective management of penetrating neck injuries based on physical examination and selective use of investigations (no zone approach) is safe and simple with low negative exploration rate and no missed injury.

[A study of the predictive value of the primary review and complementary examinations in assessing the need for surgery in patients with stab wounds in the torso]

INTRODUCTION

Observation is the gold standard for stable patients with stab wounds. The aim of the study was to analyse the value of the primary review and complementary examinations to predict the need for surgery in stab wound patients in order to decrease observation times.

METHODS

A retrospective study of stab wound patients recorded in a database. Clinical and diagnostic workup parameters were analysed. The main variable was the need for surgery.

RESULTS

A total of 198 patients were included between 2006 and 2009, with a mean injury severity score (ISS) of 7.8±7, and 0.5% mortality. More than half (52%) of the patients suffered multiple wounds. Wound distribution was 23% neck, 46% thorax and 31% abdomen. Surgery was required in 73 (37%) patients (59% immediate, 27% delayed and 14% delayed). The need for surgery was associated with a lower revised trauma score (RTS), evisceration, active bleeding, and fascial penetration. Initial and control haemoglobin levels were significantly lower in patients who required surgery. A positive computerised tomography (CT) scan was associated with surgery. There were complications in 18% of patients, and they were more frequent in those who underwent surgery. There was no difference in complication rates between immediate and delayed (P=.72). Surgery was finally required in 10% of the patients with no abnormalities in the primary review and diagnostic workup, and 6% of those developed complications.

CONCLUSION

None of the parameters studied could individually assess the need for surgery. Primary and secondary reviews were the most important diagnostic tool, but CT scan should be used more often. An observation period of 24 hours is recommended in torso penetrating wounds.

Penetrating injury neck - An unusual presentation

In a patient presenting with a penetrating injury of the neck, the problems contemplated can be very many and life threatening as well. This case demonstrates an unusual presentation of only a simple rupture of the Sternocleidomastoid muscle sparing all the vital structures beneath it following the penetration of a metallic rod of approx. 1.5 cm diameter in the neck.

Penetrating neck trauma: a case for conservative approach

BACKGROUND

Selective conservative management of penetrating neck trauma is a commonly adopted procedure to manage patients of such trauma. However, at places where trauma services are inadequate on different counts and a low-intensity military conflict is on, relevance of this approach without compromising the safety and well-being of the patient remains to be evaluated.

OBJECTIVES

The study aimed to address the relevance of selective conservative management of penetrating neck trauma in a low-intensity military conflict of Kashmir.

PATIENTS AND METHODS

This was a prospective case study of patients presenting to the ENT Head & Neck Surgery department with penetrating neck trauma for a 2-year period from June 2003 to May 2005. After a careful physical examination in the emergency room, immediate surgical intervention or a careful observation is planned. Relevant investigations in the latter group if indicated by clinical examination determined whether to operate or to continue such approach. The data were collected and analyzed.

RESULTS

Forty-six patients fulfilled the criteria to be included in the study. Eight patients (17.4%) underwent immediate surgical intervention, whereas the remaining patients (78.26%) were carefully observed for a minimum of 24 hours. Two patients of the active observation group required delayed exploration because of the close proximity of projectile to vessels. None of the patients in either group died. There was significant difference between the 2 groups in terms of hospital stay, use of diagnostic tests, and complications.

CONCLUSIONS

Selective conservative management is a cost-effective approach for penetrating neck trauma even in areas where there is relative paucity of advanced trauma services. These results further reinforce the validity of careful physical examination as a reliable tool to guide further management without necessarily resorting to expensive and at times difficult to do diagnostic tests.

Neck injuries

INTRODUCTION AND OBJECTIVE

Neck injuries are of great clinical interest because they can induce very significant consequences if not handled properly and can even lead to death. The aim of our study was to analyse external deep cervical trauma in our hospital.

MATERIAL AND METHODS

A retrospective study of all external deep neck injuries seen in a tertiary hospital over the course of 24 years that involved changes in structures related to otolaryngology.

RESULTS

Twenty patients were included in our study. From all the injuries, 45% were secondary to traffic accidents, 27% from assault with a knife and 23% from attempted suicide. The injuries were open in 15 (68%) cases and closed in 7 (32%). The most common symptom was bleeding (55%), followed by respiratory disorders (23%). On examination, the most frequent sign was the appearance of subcutaneous emphysema (27%). Only 50% of patients underwent imaging before treatment, most often a neck CT (27%). 59% of patients needed surgery, with 6 patients (27%) requiring a tracheotomy. Two of them died (9%) and 6 suffered permanent complications.

CONCLUSIONS

Cervical injuries involving ENT structures are rare in our environment, with the most common cause being traffic accidents. It is important to have standardised guidelines for the management of these patients, because they can often developed severe complications or even die if not treated properly very rapidly.

Endovascular management of neurovascular arterial injuries in the face and neck

The diagnosis and treatment of traumatic vascular injuries continues to improve as new tools and techniques are developed. In addition to locoregional hemorrhagic complications, injuries to blood vessels in the neck and face can result in ischemic injuries to the brain and cervical spinal cord. Surgical access to these lesions may be difficult, and endovascular techniques, including stenting and embolization, now serve as definitive treatments in many instances. This article reviews the endovascular management of patients with arterial injuries in the neck and face.

Penetrating neck injuries

The modern approach to patients presenting with penetrating injuries to the neck requires the cautious integration of clinical findings and appropriate imaging studies for formulation of an effective, safe, and minimally invasive modality of treatment. The optimal management of these injuries has undergone considerable debate regarding surgical versus nonsurgical treatment approaches. More recent advances in imaging technology continue to evolve, providing more accurate and timely information for the management of these patients. In this article the authors review both historic and recent articles that have formulated the current management of penetrating injuries to the neck.

Management of cervical stab wounds in low volume trauma centres: systematic physical examination and low threshold for adjunctive studies, or surgical exploration

INTRODUCTION

In Nordic countries penetrating neck injuries (PNIs) are infrequent and management has traditionally been guided by surgeons' preferences. Some form of selective non-operative approach is currently practised in most urban trauma centres.

OBJECTIVE

To examine demographic features and treatment outcome of non-ballistic penetrating neck injuries in southern Finland and provide management guidelines for centres with low volume of penetrating neck trauma.

MATERIALS AND METHODS

Retrospective analysis of 85 platysma penetrating neck injuries in two southern Finland hospitals (Helsinki University Central Hospital, HUCH and Tampere University Hospital, TaUH) was carried out using the ICD-10 based hospital databases to identify PNI-patients.

RESULTS

The incidence of admitted patients with penetrating neck injuries was 1.3/100000/year. Fifty-two (61%) injuries were caused by random acts of violence, 28 (38%) were self-inflicted and 5 (6%) were accidents. Of all 85 patients, 52 (61%) underwent operative exploration with a negative exploration rate of 65%. Hard signs for vascular or aerodigestive trauma were present in 23 (27%) patients and all of these were operated with a negative exploration rate of 30%. Two patients had no hard signs on physical examination but were operatively explored and significant injuries were found in both patients. The hospital mortality rate was 0% and the overall complication rate for operated patients was 7.7%.

CONCLUSIONS

Trauma centres managing PNIs infrequently should have an individually tailored management protocol for penetrating neck injury patients. If mandatory exploration is not practised, a systematic physical examination should be the mainstay of diagnostic work up but the threshold for adjunctive studies should be low. Although not evident by the current data, protocol-based management could be useful in decreasing treatment variation and enhancing residency training.

[Impalement injury of the neck]

In comparison to the United States or South Africa, penetrating injuries of the neck are rare in Europe. Most of these traumas are due to sharp perforation mechanisms. We report on a 43-year-old man who was admitted to the emergency room because of an impressive transcervical penetrating neck trauma inflicted by a chisel. He survived the trauma since the chisel missed all important structures of the neck. The diagnostic strategy to evaluate the dimension of the trauma was primarily based on endoscopic and surgical exploration.

Gunshots to the neck: selective angiography as part of conservative management

Trauma units all over the world are faced with an ever-increasing number of gunshot injuries. While the traditional view is that exploration is mandatory for all gunshot wounds to the neck, this issue is now often debated amongst trauma surgeons. The aim of this particular study was to assess the outcome of gunshot wounds to the neck using a selective conservative approach. Haemodynamically stable patients were investigated with angiography. Only when this proved to be positive, the patient was surgically explored. The records of 116 patients presenting with a gunshot to the neck to our trauma unit over a 3-year-period were reviewed. We studied demographics, bullet track, clinical findings, diagnostic investigations, methods of treatment, time in hospital and outcome. Seventy of the 116 patients sustained a direct hit to the neck, in 46 patients the bullet traversed the face or chest first. Eighty-five patients presented with vascular injury, 61 with an injury to the airway, 32 with an injury to the pharynx or oesophagus, and 12 with sustained neurological damage. Angiography was performed in 89 patients and was positive in 12 patients. Lesions occurred in the common carotid artery (seven), the internal carotid artery (three), the external carotid artery (three), the vertebral artery (two) and the subclavian artery (one). Five patients had more than one lesion. In total 18 patients were treated operatively by performing a neck exploration. Four patients had emergency surgery for exsanguinating bleed. Fourteen had surgery after a positive diagnostic study; 12 after angiography, 2 after another positive investigation. Ten (8.6%) patients died; three during resuscitation, three during emergency exploration, two due to respiratory failure, one postoperative and one from the adult respiratory distress syndrome (ARDS). Our results suggest that selective conservative management is a good treatment for gunshot wounds of the neck. In our experience angiography plays a key role in the detection of a major vascular injury requiring surgical exploration. Careful clinical assessment enhanced with the appropriate investigations is the cornerstone for deciding to explore a gunshot wound to the neck.

Unstable cervical spine without spinal cord injury in penetrating neck trauma

Cervical spine instability in the neurologically intact patient following penetrating neck trauma has been considered rare or non-existent. We present a case of a woman with an unstable C5 fracture without spinal cord injury after a gunshot wound to the neck. Considerations regarding the risk of cervical spine instability are discussed, as well as suggestions for a prudent approach to such patients.

Management of chest injuries--a 5 year retrospective survey

One hundred and eighty one patients with chest injuries (145 with blunt injuries and 36 with penetrating injuries) were managed using a standardized protocol at the JIPMER Hospital between 1990 and 1995. The insertion of an intercostal tube drain, provision of analgesia and oxygen was sufficient in 80 per cent of patients. An operation was required in 30 per cent of those with penetrating injuries but in only 6.2 per cent of those with blunt injuries. Most patients with chest injuries do not require an operation and can be treated adequately at District General Hospitals. Those with penetrating injuries are more likely to need surgery than those with blunt injuries.

Ferimento de hipofaringe no trauma cervical penetrante

O tratamento dos ferimentos de hipofaringe ainda é controvertido na literatura. A maior parte dos autores acredita que o tratamento preferencial consiste na exploração cirúrgica imediata, com reparo primário da lesão e drenagem ou somente a drenagem, e que o tratamento conservador estaria indicado em casos selecionados. Entre 157 ferimentos cervicais penetrantes, num período de quatro anos, encontramos sete (4,4%) casos de perfuração de hipofaringe. Destes, seis (85,7%) foram tratados cirurgicamente, cinco (71 ,4%) com sutura primária e drenagem. A taxa de mortalidade foi nula e a morbidade foi de 28,6%, sendo de 11,2 dias o tempo médio de internação.

Interventional radiology in the treatment of internal carotid artery gunshot wounds

PURPOSE

To review the indications for and techniques and results of interventional radiology in the management of internal carotid artery gunshot wounds.

PATIENTS AND METHODS

The demographics, clinical presentations, angiographic findings, methods of treatment, and outcomes were reviewed in 20 patients who underwent 21 interventional procedures.

RESULTS

Seventeen coil embolizations were successful in controlling hemorrhage. One intimal flap was compressed with balloon angioplasty, with subsequent nonoperative healing. Temporary balloon occlusions were used as a method of preoperative assessment of intracranial collateral circulation or of preoperative vascular control in three patients. There were no complications. The mortality rate was 20%.

CONCLUSION

Penetration of the internal carotid artery is a very severe injury with a high mortality rate due to neurologic sequelae. Interventional radiology plays an important role in the management of these wounds, and it often obviates surgical exploration.

Reflex mechanisms of death in missile injuries of the neck

Three cases of missile injury to the neck are reported, two homicides and one suicide. In two fatalities, the autopsy revealed contusion of the spinal cord due to direct missile injury of the cervical spine but without laceration of the spinal dura. It was concluded that the temporary cavity following penetration of the bullet caused contusion of the spinal cord with subsequent reflex cardiac arrest. In the suicide case, the entrance wound was in the mouth, the bullet track traversed the pharynx and the cervical spine with complete transection of the cord, and the bullet lodged in the right scalenus muscle. The lack of vital signs such as blood aspiration, which was expected because of the injury of the pharynx, also indicates immediate occurrence of death owing to a reflex mechanism in this case. The underlying reflex mechanisms are discussed in the light of clinical experience in the treatment of paraplegics as well as the findings in experimental contusion and transection of the cervical cord.

Transcervical gunshot injuries

Gunshot injuries across the cervical midline are not addressed in existing trauma algorithms. A retrospective study of 41 patients with transcervical gunshot wounds was undertaken to delineate injury patterns and management principles. Thirty-four of the 41 patients (83%) sustained 52 injuries to major cervical structures. Vascular (22 injuries) and upper airway (13 injuries) structures were most commonly involved. This resulted in presentation with life-threatening problems in 16 patients (39%). The in-hospital mortality was 10%. In 30 of the 36 neck explorations (83%), the findings were positive for injuries to cervical structures. Sixteen bilateral explorations were performed; in each case, cervical injury was observed on at least one side of the neck. These results indicate that transcervical injuries are excellent markers of associated visceral injury. Therefore, a policy of mandatory neck exploration and a particularly "low threshold" for bilateral exploration are the key to managing these injuries.

Airway management, penetrating neck trauma

This study was performed to determine whether clinical presentation can accurately predict which victims of penetrating neck trauma require urgent airway management. An 8-year retrospective review of all patients with a diagnosis of penetrating neck trauma seen in the emergency department of an urban teaching hospital was conducted. Of the 114 patients reviewed, 69 (60%) were intubated at some point in their hospital course. Twenty-six (23%) met our predetermined criteria for urgent airway control; 25 of these patients were intubated in the emergency department. Forty-three patients (38%) did not meet the criteria and were electively intubated either in the operating room or in the emergency department. Forty-five patients (39%) were never intubated. None of the patients in this series developed complications as a result of their airway management.

Management of penetrating neck injuries. The controversy surrounding zone II injuries

Penetrating neck injuries present a difficult challenge in management, given the unique anatomy of the neck. Controversy surrounds the approach to zone II injuries; mandatory versus selective exploration. On the basis of an extensive literature review, the authors conclude that neither approach is obviously superior. A selective approach is safe in the asymptomatic and hemodynamically stable patient, provided that accurate invasive diagnostic means are immediately available. The mandatory approach is safe, reliable, and time tested. The greatest problem appears to be the accuracy of detection of cervical esophageal injuries: Radiologic evaluation may be inaccurate, rigid esophagoscopy carries a risk of perforation, and the injury may easily be overlooked during surgical exploration.

Missed injuries. The trauma surgeon's nemesis

The multiply injured trauma patient presents a diagnostic and therapeutic challenge: that of discovering all injuries while simultaneously proceeding with resuscitation and maintaining life. Many factors involved in the initial resuscitation of the multiply injured patient, such as altered level of consciousness, hemodynamic instability, or inexperience and diagnostic oversight, may lead to missed injuries. Injuries may be missed at any stage of the management of the trauma patient, including intraoperatively, and may involve all regions of the body. Established protocols in the initial management of the multiply injured patient, such as the primary and secondary surveys of the Advanced Trauma Life Support Course, will minimize the chance of missing immediately life-threatening injuries in the emergency department. A careful intraoperative approach must be used in all patients, but especially in those with hemodynamic instability, so that all areas are examined for possible injury, rather than concentrating simply on what is known to be injured. Use of the tertiary survey, a careful re-examination of the multiply injured trauma patient, especially when he or she awakes, will help detect injuries missed during the initial evaluation. Injuries will be missed. Rather than dismissing these as occurrences that happen only to the inexperienced or incompetent, one should approach the multiply injured trauma patient with both special alertness and the humility necessary to search for diagnostic oversights. This approach will lead to early discovery of missed injuries and will minimize the consequences.

Chylous drainage from a stab wound to the neck

A 24-year-old man was assaulted and sustained a stab wound to the left lower neck. When he arrived at the emergency department, he was hemodynamically stable. Although the wound had penetrated the platysma, on initial evaluation the patient did not appear to have sustained significant injury. Closer examination of the wound revealed chylous drainage, indicating injury to the cervical portion of the thoracic duct. The patient was taken to the operating room for exploration of the wound, during which an injury to the left internal jugular vein was identified and repaired. The thoracic duct, which had been severed, was ligated. The remainder of the patient's hospital course was unremarkable. The consistent association between penetrating injury to the cervical portion of the thoracic duct and injury to neighboring vascular structures is discussed.

The management of hemorrhage from severe missile injuries using Foley catheter balloon tamponade

Foley catheter tamponade is introduced as a method of arresting hemorrhage from maxillofacial wounds due to war missiles. Three cases representing severe casualties are presented and the technique described.

Diagnosis of penetrating cervical esophageal injuries

Arterial injuries pose the greatest early threat to the patient with penetrating neck trauma and esophageal injuries, the greatest late threat. Clinical evaluation reliably identifies 80 percent of esophageal injuries, which, in our opinion, is not adequate. In 118 minimally symptomatic or asymptomatic patients with penetrating neck trauma, the combination of esophagography with esophagoscopy identified all 10 esophageal injuries in 118 patients with penetrating neck trauma. These data suggest that patients with penetrating neck trauma and minimal clinical findings should be initially evaluated with arteriography and esophagography. If the results of arteriography or esophagography are positive, then neck exploration should be performed. If the results of esophagography are equivocal, then rigid esophagoscopy should be performed. If all test results are negative, then observation is justified.

Shot in the neck in Spain (a rare cause of an isolated Horner's syndrome)

Horner's syndrome is rare. A bullet wound in the neck is a rare cause of the syndrome, and it is exceedingly uncommon for a Horner's syndrome to be the sole noteworthy clinical result of a gunshot wound of this part of the anatomy. Two cases of bullet injury of the neck are described wherein a permanent Horner's syndrome was the only important sequel.

Fifteen years' experience with penetrating trauma to the head and neck in children

To determine the extent and consequences of penetrating trauma to the head and neck in children, as well as the safety and efficacy of selective management of penetrating wounds of the face and neck, we reviewed our experience with these injuries since 1970. During this interval, 45 children aged 2 to 17 years were admitted for treatment of 37 missile wounds (MW) and eight stab wounds (SW). Most patients reached the hospital within 30 minutes of injury. The greatest single number of these injuries were due to accidents; violent crimes accounted for the remainder of injuries in which a motive for attack was known. Craniotomy was performed in neurologically viable patients only; neck exploration was reserved for those patients who presented with profuse hemorrhage, an expanding or pulsatile hematoma, respiratory distress, or violation of the esophagus, trachea, or great vessels seen on fluoroscopy, endoscopy, or angiography. Overall survival was 87% (MW 84%, SW 100%). Three of the nonsurvivors presented in extremis with gunshot (GSW) wounds to the head, and died shortly thereafter, while two who presented with similar injuries survived craniotomy but died subsequently from irreversible brain damage; one presented in shock due to massive hemorrhage (internal jugular vein transection flush with the base of the skull) and exsanguinated during attempted repair. Among the 39 survivors, 15 sustained multiple wounds, but only two presented in shock, due in both instances to tension pneumothorax. Soft tissue injuries of the scalp, face, and neck accounted for 36 of the 39 nonfatal wounds; five of these involved major cervical structures, but only four required immediate exploration.(ABSTRACT TRUNCATED AT 250 WORDS)

Panendoscopy with arteriography versus mandatory exploration of penetrating wounds of the neck

Of 193 patients with penetrating wounds of the neck, 76 had only surgical exploration; 57 had only nonsurgical exploration including one or more of the following: arteriography, bronchoscopy, laryngoscopy, esophagoscopy, and contrast-swallow esophagogram; and 60 had both surgical and nonsurgical exploration. Eighty-six patients were wounded by gunshot, 108 by stabbing. Presenting signs and symptoms were an unreliable method of predicting presence or absence of injury. Overall negative rate of surgical exploration was 50% (54% of the stabbings and 45% of the gunshots). Accuracy of nonsurgical exploration was assessed by comparing to surgery. Arteriography was 100% accurate, a combination of bronchoscopy and laryngoscopy was 100% accurate, contrast-swallow esophagogram was 90% accurate, and esophagoscopy was 86% accurate. The literature was reviewed regarding the accuracy of nonsurgical as well as surgical exploration. The one complication attributed to nonsurgical exploration was a symptomatic anemia, while there were two wound infections resulting in increased length of stay associated with negative surgical exploration. Overall mortality rate was 5.6%. The average length of stay for nonsurgical exploration only was 2.8 days, for negative surgical exploration was 4.2 days, and for positive surgical exploration was 9.5 days. Financial cost of a negative surgical exploration was $3185, while for four-vessel cerebral arteriography with panendoscopy it was $3492. More studies need to be done, particularly concerning venography and esophagoscopy. However, considering the fact that surgical exploration should by no means be considered 100% accurate, the data in this study support the fact that arteriography with panendoscopy represents an equally safe and acceptable method of exploration of penetrating wounds of the neck for stable patients without specific signs and symptoms of injury and can be expected to result in a reduced number of negative surgical explorations and their associated morbidity as well as a reduced length of hospital stay, although at a slightly higher financial cost when compared to mandatory surgical exploration.

Penetrating neck trauma: consensus and controversies

Proper emergency evaluation and treatment of the victim of penetrating neck trauma requires a thorough knowledge of cervical anatomy and of the injuries that are likely to occur. Nonoperative studies supplement the physical examination in the evaluation of these patients, and may either assist in the operative approach or allow for safe observation of the patient. The debate concerning exploration and observation of penetrating neck wounds continues.

Penetrating neck wounds. Mandatory versus selective exploration

We reviewed the records of 257 patients (ages, 16-83 years) with penetrating neck wounds (119 gunshot and 138 stab) managed at Harlem Hospital Center. Among the first 148 patients, 134 were managed by mandatory neck exploration; 42 had injuries (31%), and 92 (69%) had no injury. There were four deaths (3%) and seven (5%) morbidities. Because of the high rate of unnecessary operations, the following 109 patients were managed selectively, 40 by exploration, and nine of the 40 (22%) had no injury; 69 were observed and did not require subsequent operative intervention. There were six deaths (5.5%) and six morbidities (5.5%) among the second group. Morbidity and mortality were unrelated to the method of management but related to the type and severity of injuries, associated injuries, preexisting illnesses, and age of the patients. The frequency of operations for penetrating neck wounds without structural injuries was minimized in the selective exploration group.

Operation or observation for penetrating neck wounds? A retrospective analysis

A review of 83 patients with penetrating neck wounds was performed to assess the relative merits of operation versus observation. Fifty patients (60 percent) underwent immediate surgery, 28 of whom (56 percent) had no significant neck injury. There were no deaths and only two complications (4 percent). Thirty-three patients (40 percent) were treated with initial observation, one of whom required subsequent surgery. In the latter group, there were also no deaths and two complications (6 percent). Length of hospital stay did not differ between patients with negative findings on exploration and those observed. When clinical signs as indications for surgery were present, management was more often correct than when signs were absent (82 and 52 percent, respectively), but the presence or absence of signs correctly predicted injury or lack of injury in over 80 percent of the patients. These data demonstrate the safety and efficacy of selective observation of patients with penetrating neck trauma, and confirm that clinical signs are a reliable indicator of significant injury.

Selective management of penetrating neck wounds

Of 67 patients with penetrating neck wounds admitted to the hospital between 1969 and 1979, 22 (32.8%) were taken to the operating room and 14 (63.6%) were found to have major structural damage. Three patients died (4.4%), all as a direct result of their associated head injuries and none as a result of their neck wounds, regardless of management. Five patients (7.4%) had complications. The average hospital stay for patients undergoing surgery was 4.9 days; for those observed with multiple injuries, 4.6 days; and for those observed with isolated neck wounds, 2.4 days. Indications for selective exploration are presented.

Selective management of gunshot wounds to the neck. Report of a series and review of the literature

Thirty-two patients with gunshot wounds to the neck, 13 with multiple pellet injuries and 19 with single missile injuries, were managed selectively. Although 3 of the 32 patients died in the hospital, no death was attributable to the neck injury. This experience and a review of the literature support the concept of selective management of penetrating neck injuries with intervention based on specific indications.

Evaluation and management of penetrating wounds of the neck: the role of emergency angiography

With the use of emergency angiography, careful observation, and monitoring, 40 consecutive patients with penetrating wounds were selectively managed. Eleven patients were operated on with one negative exploration and one death. Twenty-nine patients were observed after negative angiography without operation on the neck and were subsequently discharged without' overlooking a significant vascular or visceral injury or amy complication. We believe this policy to be safe and effective. It should reduce the number, the morbidity, and the cost of needless mandatory surgical explorations and should guard against clinically undetected serious injuries. Operations should be reserved for those patients with clinically obvious servere vascular or visceral injury and for those with radiographically demonstrated significant lesions.